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2001. FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. | PSNet
      psnet.ahrq.gov/issue/fda-requiring-color-changes-duragesic-fentanyl-pain-patches-aid-safety-emphasizing-accidental
      August 05, 2020 - Press Release/Announcement FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. Citation Text: FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that…

2002. Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? | PSNet
      psnet.ahrq.gov/issue/there-july-phenomenon-pediatric-neurosurgery-teaching-hospitals
      May 23, 2018 - Study Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? Citation Text: Smith ER, Butler WE, Barker FG. Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? J Neurosurg. 2006;105(3 Suppl):169-76. Copy Citation Format: Go…

2003. Patient harm from cardiovascular medications. | PSNet
      psnet.ahrq.gov/issue/patient-harm-cardiovascular-medications
      August 11, 2021 - Review Patient harm from cardiovascular medications. Citation Text: Paradissis C, Cottrell N, Coombes ID, et al. Patient harm from cardiovascular medications. Ther Adv Drug Saf. 2021;12:204209862110274. doi:10.1177/20420986211027451. Copy Citation Format: DOI Google Scholar…

2004. The effects of emergency department staff rounding on patient safety and satisfaction. | PSNet
      psnet.ahrq.gov/issue/effects-emergency-department-staff-rounding-patient-safety-and-satisfaction
      November 16, 2022 - Study The effects of emergency department staff rounding on patient safety and satisfaction. Citation Text: Meade CM, Kennedy J, Kaplan J. The effects of emergency department staff rounding on patient safety and satisfaction. J Emerg Med. 2010;38(5):666-74. doi:10.1016/j.jemermed.2008.…

2005. From guideline to order set to patient harm. | PSNet
      psnet.ahrq.gov/issue/guideline-order-set-patient-harm
      October 10, 2017 - Commentary From guideline to order set to patient harm. Citation Text: Shah SD, Cifu AS. From Guideline to Order Set to Patient Harm. JAMA. 2018;319(12):1207-1208. doi:10.1001/jama.2018.1666. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XM…

2006. Infections associated with reprocessed flexible bronchoscopes. | PSNet
      psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes
      March 11, 2015 - Press Release/Announcement Infections associated with reprocessed flexible bronchoscopes. Citation Text: Infections associated with reprocessed flexible bronchoscopes. FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015. Copy Citation …

2007. U.S. Food and Drug Administration Precertification pilot program for digital health software: weighing the benefits and risks. | PSNet
      psnet.ahrq.gov/issue/us-food-and-drug-administration-precertification-pilot-program-digital-health-software
      September 25, 2008 - Commentary Emerging Classic U.S. Food and Drug Administration Precertification pilot program for digital health software: weighing the benefits and risks. Citation Text: Lee TT, Kesselheim AS. U.S. Food and Drug Administration Precertification Pilot Program for …

2008. The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. | PSNet
      psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
      May 26, 2021 - Commentary The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Citation Text: The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248. Copy…

2009. Shifting supervision: implications for safe administration of medication by nursing students. | PSNet
      psnet.ahrq.gov/issue/shifting-supervision-implications-safe-administration-medication-nursing-students
      January 27, 2021 - Study Shifting supervision: implications for safe administration of medication by nursing students. Citation Text: Reid-Searl K, Moxham L, Walker S, et al. Shifting supervision: implications for safe administration of medication by nursing students. J Clin Nurs. 2008;17(20):2750-7. doi…

2010. Blending evidence and innovation: improving intershift handoffs in a multihospital setting. | PSNet
      psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital-setting
      September 23, 2017 - Commentary Blending evidence and innovation: improving intershift handoffs in a multihospital setting. Citation Text: Thomas L, Donohue-Porter P. Blending evidence and innovation: improving intershift handoffs in a multihospital setting. J Nurs Care Qual. 2012;27(2):116-24. doi:10.1097…

2011. Why July matters. | PSNet
      psnet.ahrq.gov/issue/why-july-matters
      October 13, 2018 - Commentary Why July matters. Citation Text: Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912. doi:10.1097/ACM.0000000000001196. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2012. Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. | PSNet
      psnet.ahrq.gov/issue/hospira-carpuject-pre-filled-cartridges-drug-alert-products-may-contain-more-intended-fill
      August 05, 2020 - Press Release/Announcement Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. Citation Text: Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. MedWatch Safety Alert. S…

2013. Implementing a warm handoff between hospital and skilled nursing facility clinicians. | PSNet
      psnet.ahrq.gov/issue/implementing-warm-handoff-between-hospital-and-skilled-nursing-facility-clinicians
      March 04, 2020 - Study Implementing a warm handoff between hospital and skilled nursing facility clinicians. Citation Text: Britton MC, Hodshon B, Chaudhry SI. Implementing a Warm Handoff Between Hospital and Skilled Nursing Facility Clinicians. J Patient Saf. 2019;15(3):198-204. doi:10.1097/PTS.00000000…

2014. Root cause analysis of transfusion error: identifying causes to implement changes. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-transfusion-error-identifying-causes-implement-changes
      August 15, 2018 - Commentary Root cause analysis of transfusion error: identifying causes to implement changes. Citation Text: Elhence P, Veena S, Sharma RK, et al. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion (Paris). 2010;50(12 Pt 2):2772-2777. doi:10.…

2015. Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system. | PSNet
      psnet.ahrq.gov/issue/measuring-faculty-reflection-adverse-patient-events-development-and-initial-validation-case
      September 20, 2011 - Study Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system. Citation Text: Wittich CM, Lopez-Jimenez F, Decker LK, et al. Measuring faculty reflection on adverse patient events: development and initial validation of a …

2016. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. | PSNet
      psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-food-and-drug-administration-1998-2005
      June 07, 2016 - Study Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Citation Text: Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Arch Intern Med. 2007;167(16):1752-9. Copy Citation Forma…

2017. Saving Patient Ryan- can advanced electronic medical records make patient care safer? | PSNet
      psnet.ahrq.gov/issue/saving-patient-ryan-can-advanced-electronic-medical-records-make-patient-care-safer
      February 11, 2014 - Study Saving Patient Ryan- can advanced electronic medical records make patient care safer? Citation Text: Saving Patient Ryan- can advanced electronic medical records make patient care safer? Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059. Copy Citation …

2018. Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. | PSNet
      psnet.ahrq.gov/issue/inter-and-intra-rater-reliability-classification-medication-related-events-paediatric
      August 20, 2018 - Study Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. Citation Text: Kunac DL, Reith DM, Kennedy J, et al. Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. Qual Saf …

2019. Organizational factors that promote error reporting in healthcare: a scoping review. | PSNet
      psnet.ahrq.gov/issue/organizational-factors-promote-error-reporting-healthcare-scoping-review
      June 01, 2022 - Review Organizational factors that promote error reporting in healthcare: a scoping review. Citation Text: Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166. Copy…

2020. Academy Newsletter | The Academy
      integrationacademy.ahrq.gov/academy-newsletter
      June 24, 2025 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…